This document is intended as a review of legal and psychiatric factors to offer practical guidance in the performance of forensic evaluations. In criminal contexts, one of the important collateral sources can be information obtained from police officers and witnesses to alleged criminal conduct. The American Medical Association's Code of Ethics states that physicians have an obligation to assist in the administration of justice.22 Forensic psychiatrists are physicians who are trained to diagnose and treat patients within the ethics principles embedded in the doctorpatient relationship. Although their article concentrated on the written report, it suggested that psychiatrists "lis-tened hard to the voices they heard" (Ref. In addition, caregivers or family members of a person who is undergoing a forensic assessment may be reluctant to provide accurate or complete information if they are concerned that full information may harm their interests. Many forensic evaluators provide a caveat that their opinions are based on the information currently available and that additional information may require further consideration and therefore could alter the opinion rendered. Again, experts are cautioned against relying solely on web sites of developers of the instruments. The family history may yield clues about the evaluee's early development and other psychosocial considerations. Epub 2015 Jun 8. 0000029226 00000 n Other authors have developed syntheses of these frameworks based on compassion,35 robust professionalism,28,29,31 and an acknowledgment of the tension in holding simultaneously to both medical ethics and the demands of the criminal justice system.32,33 The AAPL Ethics Guidelines call for adherence to honesty, striving for objectivity, and respect for persons in the organization's attempt to generate a workable code of ethics for forensic psychiatric practice.39. Most people believe that the legal system is fair, but some disagree46 and may have complex sociocultural reasons for their belief.175 Even personal concepts of wrongfulness may be steeped in cultural and social definitions, and these concepts may be taken into consideration in certain situations, such as evaluations for mitigating factors in sentencing.164, Aggarwal163 and Kirmayer174 both argued that situating behavior in its cultural context often provides insight and clarification into an individual's reasoning process. /N 51 First, forensic examiners should always maintain a humane and respectful approach to evaluees. Occupational history can provide insight into the evaluee's personality, including attitude toward authority. 2.01 Scope of Competence. Allegations involving double denial conform to the following theme: I am not responsible because of reason one, and, if this is not accepted, I am also not responsible because of reason two. Genuine insanity defenses are usually associated with only one psychotic explanation of why the defendant did not appreciate the wrongfulness of the act, not with dual explanations. Methods useful in managing countertransference include consultation with a colleague, clinical case conferences, ethics training, and training in managing aggressive behavior. . In the real world, evaluees can easily research the diagnostic symptoms before an evaluation and in some circumstances may be coached to give the desired answers. 147, p 80). The expert opinion may benefit from interviews with several sources, including family members, colleagues, friends, victims, and witnesses, and the sources will vary by type of assessment. For these reasons, it is most appropriate to consider the degree of impairment the symptoms are causing and the degree of disability affecting the competence or capacity under evaluation. In certain jurisdictions, and particularly in multidisciplinary team settings, interview data gathered by ancillary mental health professionals may be used and incorporated into the forensic evaluator's report. >> The test was originally standardized among only Western populations that were almost exclusively white in origin; therefore, some suggest that the PCL-R should be used with caution in nonwhite and non-Western groups, although the manual of the test addresses the possibility and counters the argument.164 Because the administration of the PCL-R requires semistructured interviews and examiner rating, some argue that knowledge of cultural concerns is essential when using the test.120, In addition, even parts of the formal mental status assessment may require adaptation. For some types of assessments (e.g., competence to stand trial), only one interview may be necessary. Two aspects of civil forensic psychiatric assessments may not be encountered in criminal assessments. The commentary accompanying the consent guideline in the American Academy of Psychiatry and the Law's (AAPL's) Ethics Guidelines for the Practice of Forensic Psychiatry provides that consent for forensic assessment is different from consent for forensic treatment, and that forensic psychiatrists should therefore be familiar with local . In some cases, psychiatrists have testified about the future dangerousness of a defendant, whereas in others, they have been asked about the methodology of such risk assessments for the defense. Hence, in certain cases it is important to attempt to interview the evaluee as soon as possible after the crime, to observe the evaluee's mental state as close as possible to the alleged commission of the crime. An important concept to remember when talking about people with ID is people first. 10, -, 16 A review of the literature concluded that the level of practice falls short of professional aspirations for the field, although there have been incremental improvements during the 1990s. Therefore, questions about the adequacy of treatment are usually posed. These reports can be critical to forensic assessment because they provide the factual allegations that serve as the basis for criminal charges. Mossman and colleagues19 attempted to measure the accuracy of assessments in a quantitative manner. They should also be prepared to articulate, in testimony or in a report, why they have not used instruments that other experts have employed. Through careful assessment, the forensic psychiatrist's role in exploration of the cultural contexts of behavior may also help explain the behavior.176, In addition to the forensic psychiatrist's duty to provide culturally informed assessments, cultural concerns arise in other forensic settings. Inquiry should also be made about the evaluee's financial status, current living arrangement, children, and custody and access arrangements for the children. 0000030672 00000 n For example, forensic experts should not administer a psychological test to evaluees outside the standardization sample of the test (e.g., the Static 99 cannot be used to assess risk in female sex offenders).117. In a general psychiatric practice, the patient presents signs and symptoms to a psychiatrist. Short- and long-term stressors that may trigger such behavioral problems in individuals with ID or dual diagnosis include frustration with difficulty communicating, using problematic behavior as a means of communication, or both; alterations in conditions, such as medication changes, loss of caretakers or loved ones, physical discomfort or illness, stigmatization, or bullying; emotional conditions resulting from psychiatric disorders (in cases of dual diagnosis); and frustration due to realization of mental deficits.161. Resnick and Knoll216 proposed a model that incorporates many of the above-noted factors, thereby serving as a useful guide for experts. Psychological testing may be useful in identifying the presence of such misrepresentations (see Section 10.5, Malingering and Dissimulation).118. Child and Adolescent Assessments: Special Considerations. The assessment should be as complete as possible under the circumstances. The assessment of competence to stand trial requires specific questions regarding whether the evaluee is competent to assist or instruct counsel and can participate in making decisions during the instant legal case. The validity of a psychiatric report is greatest when those skills can be applied. For example, in an evaluation of competence to stand trial, the evaluator may want to assess the defendant's ability to provide a rational account of the charges and to appreciate the nature of the allegations, to elucidate whether the evaluee has the capacity to confirm or refute the allegations when instructing the defense attorney and when appearing in court. In particular, a contemporaneous recording of the evaluee in a disturbed mental state that is produced at trial some time later, after he has recovered, can significantly enhance the credibility of the testimony. /Encoding /WinAnsiEncoding In such cases, the defendant's version of the offense may demonstrate what is called a double denial of responsibility.216 Common examples include some type of disavowal of having committed the crime, yet a simultaneous attribution of the crime to psychosis. In certain circumstances, the psychiatrist may wish to have a third party present to ensure safety or to have an objective observer in case of a litigious or difficult evaluee. The most difficult differential diagnosis of mutism is in distinguishing a conversion disorder from malingering (i.e., whether the evaluee's mutism is under voluntary control). For example, blacks are diagnosed more frequently than whites with psychotic disorders and less often with mood and anxiety disorders.166,167 These diagnostic differences may be influenced by cultural differences in communication and interaction styles, values, and belief systems in the doctorpatient dyad. If the evaluee is intellectually or developmentally disabled or has a physical disability or neurological disorder, prenatal, perinatal, and neonatal illnesses and events may be relevant. AAPL Practice Guideline for the Forensic Assessment. By contrast, most forensic actuarial instruments are based on smaller samples with unique characteristics, which may limit their generalizability. They may even attend an interview with a recording device. On the other hand, anxiety resulting from the defendant's threatening behavior may provoke the evaluee to use sedatives or other substances in an attempt to self-medicate. For example, a child may feel more obliged to cooperate because of deference to authority,150 be less likely to understand the consequences of certain admissions, or be overly trusting of the interviewer. There may be questions about how long the impairments are likely to last, whether further improvement is likely if treatment is optimized, and whether the evaluee has reached maximum medical improvement. Some areas, such as developmental disability and cultural competence in forensic psychiatric contexts, as well as risk assessment, have come to the fore in recent years and continue to be the subject of intensive research. State evaluators investigating an abuse or neglect report do not need consent in most jurisdictions. Reviewing the evaluee's specific claims outlined in the complaint and other legal documents may assist in addressing the concerns that are the focus of the litigation. Furthermore, evaluees in forensic contexts may exaggerate or minimize their symptoms for several reasons: for example, to maximize their injury in civil cases or to minimize their involvement or culpability in criminal cases. /Type /Catalog Criminal assessments may require interviews that explore present-state examinations (e.g., competence to stand trial) or that elucidate past mental states (e.g., criminal responsibility and competence to waive Miranda rights).85. Whenever possible, the evaluator should use collateral sources of information, which may provide facts or clues that aid in the assessment, such as a family history of suicide or suicide attempts, violent behavior, criminal involvement, and legal difficulties. AAPL Practice Guideline for the Forensic Evaluation of Psychiatric Disability J Am Acad Psychiatry Law. 0000001012 00000 n Disability insurance policies may require claimants to be receiving treatment appropriate for their condition. Early sexual behavior may be the forme fruste of a paraphilia. In selecting a measure, it is important to find one that uses multiple detection strategies. For example, the Test of Memory Malingering (TOMM) has demonstrated a high rate of detection of malingering in groups of subjects with ID.199. The site is often determined by the purpose of the assessment. The presence of an ID often renders the evaluee poorly equipped to provide a history. The collateral information to be sought depends on the specific question posed by the referring agent and the circumstances of the case. Common examples of physical injuries that can lead to mental injury include nonvehicular accidents, vehicular accidents (e.g., motor vehicle, airplane), natural disasters (flood, fires, earthquakes), and physical or sexual abuse. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 257 ] For evaluees with severe mental illness, the evaluator may find it necessary to arrange for treatment. The most frequent types of assessment are for risk of violence, inappropriate sexual behavior, and criminal recidivism. In addition to warnings concerning the lack of confidentiality routinely made in forensic assessments, an evaluator who is recording an interview should inform the evaluee in advance that the interview will be recorded and that the recording becomes a legal document that may be introduced in court if the evaluator is used as an expert. /FontName /NILMNI+GillSans-Bold When symptoms such as memory loss, dissociation, or depersonalization during an offense are claimed, it is important to consider whether the symptoms, if genuine, were precipitated by the offense itself. Systematic inquiries are especially helpful in obtaining a full substance use history. Weinstock and colleagues38 noted that the conflicting values of law and medicine make balancing these roles a formidable task. Similarly, ascertaining the evaluee's ability to follow through on commitments such as education and career helps to complete the picture. /Encoding /WinAnsiEncoding Details of both a formal history of mental health treatment and symptoms that may never have been brought to the attention of a mental health professional should be elicited. >> /CharSet Special considerations in sentencing include young-offender statutes that require consideration of developmental disabilities; sexual offenses, which may involve a period of civil commitment after the sentence; and special assessments, which determine the appropriateness of a drug court, mental health court, or other special program for an offender with a mental disorder. In particular, neurological disorders, such as seizures, the sequelae of traumatic brain injury, and certain endocrine disorders, should always be considered when formulating cases involving impulsivity, violence, or sexually anomalous behavior. Adopted May, 2005. A measure that reveals repeated failures on very simple items is insufficient, as malingering evaluees may successfully mimic mild to moderate impairment, which is enough to achieve their objective. In this regard, the timing of the interview may in some cases make a critical difference. This strategy enables a neutral exploration of the evaluee's narrative, state of mind, and style of presentation.7,64 Open-ended questions can help the individual to become comfortable with talking to the evaluator and enable the examiner to establish a rapport with the evaluee before moving to more difficult material about the forensic matter at hand.36,45 Closed questions, which demand a yes-or-no answer, may have their place in specific matters, but, as part of the strategy for seeking objectivity and honesty, the evaluator should guard against leading questions or questions that limit responsiveness from the evaluee. The evaluee should be asked to provide descriptions of situations in which occupational functioning was impaired. Similarly, in sentencing assessments, the evaluator should use police reports and official documentation of the offense to enhance understanding of the details of the criminal conduct and in elucidating patterns of conduct and the relationship of mental illness or substance use to the crime. As part of an unique subject of the Magazine on evidence-based forensic exercise, this article examines three published competency measures: the MacArthur Competence Assess Tool-Criminal Adjudication (MacCAT-CA), the . For that matter, in any assessment related to mental status at a particular time point (e.g., competence to waive Miranda rights), the evaluator should understand the history and context of the time in question and relate it to the thoughts, perceptions, feelings, and psychological functioning of the evaluee at that time. Careful observations of the evaluee should be documented and records and collateral information reviewed. In disability-related cases, the interview data should be sufficient to allow for an assessment of occupational performance.72 The assessment should determine whether the evaluee is a valued worker who has a stable work history, as evidenced by promotions to positions of increased authority, consistently high job performance ratings, steady pay increases and bonuses, and commendations, or, alternatively, whether the evaluee has a poor work history, as evidenced by dismissal from numerous jobs, difficulty maintaining a job for a significant amount of time, poor job performance ratings, and numerous conflictual relationships with supervisors, coworkers, and members of the public. stream The possibility of conflicts should be explored during the initial contact with the referring agent, but conflicts may come to light only later in the case. A limited physicianpatient relationship may still be present, even in forensic assessments, placing some continued obligation on the physician-examiner.36,45 However, the forensic expert must make it clear that the assessment is not for the purposes of treatment and that the rules of confidentiality are different and governed by the requirements of the legal system.36,46. s{bay*WV;Xv,j0Wr*U6lGVpfAod.1f7j-XvY&V{N67bQ="_+v$Zp)as"XE+i[y' p8IQpD~,)>R:-" $/??lM,C)[JlWv39 9~5K,@kQpKZO"#V~I[vm4,g?FR&S_Ld>jc8f-$&F:!l2Hz Finding a quiet, private place can limit this confounding factor. Thus it reflects a consensus among members and experts about the principles and practice applicable to the conduct of evaluations of competence to stand trial. Ideas of harming others are sometimes revealed through a series of questions relating to troubling or intrusive thoughts. The competence assessment for standing trial for defendants with mental retardation (Cast-MR): a validation study, Competence Assessment for Standing Trial for Defendants with Mental Retardation, Interdisciplinary Fitness Interview-Revised: A Training Manual, Psychometric properties of the MacArthur Competence Assessment Tool: Criminal Adjudication, Mental Health, Law and Policy Institute, Simon Fraser University, Evaluation of Competency to Stand Trial-Revised (ECST-R) and Professional Manual, The METFORS Fitness Questionnaire (MFQ): a self-report measure for screening competency to stand trial, Clinical Assessment of Malingering and Deception, Violent Offenders: Appraising and Managing Risk, A step by step guide to assessing sexual predators, Evaluating Sex Offenders: A Manual for Civil Commitments and Beyond, Lishman's Organic Psychiatry: A Textbook of Neuropsychiatry, Phallometric Testing with Sexual Offenders: Theory, Research, and Practice, Laboratory measurement of penile response in the assessment of sexual interests, Sex Offenders: Identification, Risk Assessment, Treatment and Legal Issues, Visual reaction time: development, theory, empirical evidence and beyond, Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues, Dangerous Sex Offenders: A Task Force Report of the American Psychiatric Association, Predicting relapse: a meta-analysis of sexual offender recidivism studies, Evidential basis for the assessment and treatment of sex offenders, The measurement of sexual preference: a preliminary comparison of phallometry and the Abel assessment, The Sex Offender: Theoretical Advances, Treating Special Populations and Legal Developments, Daubert v. Merrell Dow Pharmaceuticals, 509 U.S. 579 (1993), Forensic assessment in personal injury litigation. A formal job description obtained from the employer can be used to define essential tasks. The psychiatric history should include reports concerning onset, duration, and severity of symptoms, as well as those requiring hospitalization. In general competence, there are essential elements that should be considered, including the evaluee's awareness of the situation, factual understanding of the problems involved, appreciation of the likely consequences, ability to manipulate information rationally, ability to function in his own environment, and ability to perform the tasks demanded of him. Interviewing children and adolescents involves techniques different from those used in interviewing adults, and therefore requires special training. Fourth, disability assessments (such as Social Security assessments) may lead to civil litigation when the evaluated child or adolescent is denied financial benefits and coverage. Recognizing the unique aspects of this practice, which is at the interface of the professions of psychiatry and the law, the Academy presents these guidelines for the ethical practice of forensic psychiatry. /Type /Font /XHeight 461 Sometimes lawyers will obtain video recordings of evaluees engaging in various activities that may be inconsistent with their history. 72, p 307). The principles summarized in Section 5.2, Confidentiality, are designed to ensure that the evaluee understands the principles and limits of confidentiality in the forensic assessment. If an evaluee assaults the forensic evaluator, the evaluator should consider withdrawing from the assessment, as his objectivity may be compromised. In particular, different groups may display different affects in the presence of strangers.164 An expressed belief might be interpreted as a delusion by an evaluator who is unfamiliar with religious beliefs in another culture. For example, many disability insurance carriers require a multiaxial DSM diagnosis, although this may change with the application of DSM-5. The examination will elicit information about the frequency and severity of psychiatric symptoms, including mood, anxiety, trauma-related symptoms, thought content, thought form, delusional beliefs, perceptual disturbances, cognition, and concentration and relevant comments, insights, and judgment.36 The mental status assessment is usually helpful in formulating a diagnosis and in assessing the evaluee's strengths and vulnerabilities resulting from psychiatric symptoms or cognitive impairments. If needed for the safety of the evaluator, assessments may be conducted by telephone, with the interviewer and the evaluee separated by a Plexiglas partition. For litigation involving claimed mental harm, the expert should request important legal documents. Self-report measures of sexual behavior and attitudes provide another window into the mind of the evaluee.240 Other investigations include sexual preference testing by PPG and VRT (see Section 8.6, Penile Plethysmography and Visual Reaction Time Screening). AAPL Practice Guideline for the * Forensic Assessment 1. However, the Court did not go on to define a specific competence standard. We describe several state examples of changing practice in order to highlight the initial barriers, and potential benefits, to addressing additional clinical . Content of Assessment: Civil (Psychic Injury). As with other guidelines, it is hoped that this one will contribute to practice improvement and professional development in forensic assessment and, ultimately, to better outcomes in justice and mental health. They are unlikely to give a successful imitation of the subtle signs of schizophrenia, such as symptoms of deficits (e.g., flat affect, alogia, and avolition), impaired relatedness, digressive speech, or peculiar thinking. This document does not cover report-writing or testifying. /StemV 145 An exploration of how psychiatric diagnosis and various symptoms may interfere with any or all of the types of competence is essential. Arguments for others being present are often made on the basis that the child needs protection or support because of the risk of harm during the assessment. A confounding variable is that some individuals with ID enjoy the attention they receive for disruptive behavior, especially when other family members or staff members constitute the audience. For example, a female evaluee in a sexual harassment case who was stalked by an ex-boyfriend may be especially offended or unnerved when a male coworker absentmindedly stares in her direction, although the coworker's behavior was not intended to be discriminatory or threatening. ID often results in increased vulnerability to stress and in sensitivity to changes in the environment. Recording should not be done surreptitiously. /ItalicAngle 0 .;LSpD$3&/\ \mqti9gM$M$Ft[$3? In many jurisdictions, plaintiffs cannot be required to travel more than a specified distance to attend an assessment. It can also be used to detect malingering of intellectual disability or cognitive impairment, as evaluees tend to take a broad-based approach to malingering across the spectrum of disorders. The authors also drew attention to aspects of the interpersonal relationships between parties, which may be significant. J Am Acad Psychiatry Law. The AAPL Ethics Guidelines state: Specific competence entails four elements, some of which are the same as general competence: communication of a choice sustained long enough to implement it, factual understanding of the problems involved, appreciation of the situation and its consequences, and rational manipulation of information.97, Some of these specific competence assessments may involve consent to treatment,98 guardianship evaluations,99 testamentary capacity,100 financial competence, and competence to enter into a contract.97. /PageMode /UseNone Some nutraceuticals (such as ginkgo biloba or St. John's wort) may be significant, and the evaluator may learn of their use by asking questions such as, Are you taking any pills or supplements for your health?. Enter multiple addresses on separate lines or separate them with commas. /Subtype /Type1 By contrast, in malingering, there is frequently a history of antisocial conduct, an extensive criminal record, and a refusal to submit to psychological testing. /Resources 188 0 R It is intended to . Other medical factors that may be relevant to the forensic assessment include intellectual or developmental disability, narcolepsy, and sleep apnea. /T 300358 /Descent -230 /Length 506 Therefore, experts should be aware of how closely the evaluee resembles the sample on which a given test is based.
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